Provider Demographics
NPI:1619109147
Name:WELLS EYE CENTER INC
Entity Type:Organization
Organization Name:WELLS EYE CENTER INC
Other - Org Name:LOGAN EYE CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRISTS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THAD
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-726-2022
Mailing Address - Street 1:105 ROBINS WAY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1129
Mailing Address - Country:US
Mailing Address - Phone:270-726-2022
Mailing Address - Fax:
Practice Address - Street 1:105 ROBINS WAY
Practice Address - Street 2:SUITE 206
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1129
Practice Address - Country:US
Practice Address - Phone:270-726-2022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2010-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1770DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01076Medicare PIN